Injuries to the Elbow and Forearm

1. Injuries to the Elbow and Forearm Tintinalli Chapter 270

2. Posterior Elbow Dislocation • Mechanism: FOOSH (fall on an outstretched hand) • Clinically: held in 45 degree flexion, prominent posterior olecranon, significant swelling • Assess neurovascular status before and after reduction • Ulnar, radial, median nerve fxn and brachial artery • X-ray: lateral-ulna & radius displaced posteriorly • Reduce under conscious sedation. Distal traction at wrist with humerus immobilization. Flex the elbow with posterior pressure to the distal humerus. Post reduction films.

3. Posterior Elbow Dislocation

4. Anterior dislocations • Mechanism-elbow flexed with a blow to the olecranon. • Forearm is elongated and supinated • Higher incidence of vascular damage • Reduction: immobilize the humerus with in-line traction to the wrist and downward/backward pressure on the proximal forearm

5. Radial Head Subluxation • Children<5 y.o. • MOI-longitudinal traction on the hand or forearm with arm in pronation • Presents: elbow flexed and arm in passive pronation, unwilling to move it • Xrays are usually normal • Reduce by placing the thumb on the radial head and supinating the forearm and flexing the elbow

6. Elbow Radiograph • Post. Fat pad-never normal on x-ray. Represents swelling of the joint capsule and probably fx. • Ant. Fat pad-a small one may be present on normal x ray. If superior and anteriorly displaced, could represent a fracture. • Anterior humeral line-line down the ant. surface of the humerus normally transects the middle of the capitellum. With a supracondylar extension fracture the line may transect the ant. 1/3 or completely ant. to the capitellum

7. Elbow Radiograph Fat Pad Sign

8. Supracondylar Extension Fracture • MOI: FOOSH • Clinically: edema, tenderness at elbow, olecranon prominent, depression proximally over triceps • X-ray: Posterior fat pad, tranverse fx line • Treatment • Nondisplaced: ortho consult-post. splint with the arm at 90 degrees • Displaced: require surgical reduction. If vascular compromise, try to reduce once in the ED

9. Supracondylar Flexion fractures • MOI: direct anterior force against flexed elbow • Xray: anterior displacement of distal fragment (frequently open) • Treatment • Nondisplaced-immobilization with early ortho follow up • Displaced-emergent ortho consult for reduction and pinning

10. Distal Humerous Fractures • Epicondyle Fractures • Lateral (rare) • Avulsion usually • Immobilize in 90degrees flexion, ortho referral one week • Medial • MOI: repeated valgus (throwing) or direct blow • Presentation: pain over medial elbow worse with supination • Risk: ulnar nerve injury • Tx: nondisplaced – nonoperative; displaced – internal fixation

11. Distal Humerous Fractures • Condylar fractures • Lateral (more common) • Children • MOI: direct blow, FOOSH, varus stress • Medial • Children • MOI: transmitted force from ulna, FOOSH, valgus • Treatment • Ortho consult for surgical correction

12. Radial Head Fractures • Most common fx of elbow • MOI: FOOSH • Clinically: pain in lateral elbow with pronation & supination • Xray: • Radiocapitellar line: line drawn from center of radial shaft should transect radial head and capitellum • Abnormal fat pad • Tx • Displaced: surgical • Nondisplaced: sling immobilization, ortho referral 1 week

13. Olecranon fractures • MOI: direct blow to point of elbow, FOOSH with elbow flexion • Clinically: pain posterior elbow, swelling, crepitus • Triceps function may be compromised • Ulnar N. injury common • Tx • Nondisplaced: immobilize in flexion, forearm neutral • Displaced >2mm ORIF

14. Forearm Fractures • Radius and ulna: joined by interosseous membrane results in injury to both • Requires high force, MVA, fall from height • Complications: reduced sup/pro, osteo, neurovascular compromise, compartment syndrome, Volkmann’s contracture

15. Nightstick Fracture • Isolated Ulnar Fracture • MOI: Direct blow to forearm (defensive) • Tx • Nondisplaced: long arm splint, close f/u • Displaced >10 degrees of angulation or >50% of the width: ORIF

16. Galeazzi fracture • Fracture of distal third of radial shaft with a distal radioulnar dislocation • MOI: FOOSH in forced pronation, direct blow • Xray • Short oblique or tranverse with dorsal lateral angulation • Radioulnar joint injury subtle (increased distal radioulnar joint space on AP view) • Tx: ORIF

17. Monteggia’s Fracture-Dislocation • Ulnar shaft fx with radial head dislocation • Four Types: • Type I: prox/middle 1/3 ulna, ant dislocation radial head • Type II: prox/middle 1/3 ulna, post dislocation • Type III: fx ulna distal to coronoid process, lateral dislocation • Type IV: prox/middle 1/3 ulna and fx prox 1/3 of radius with ant dislocation

18. Monteggia Fracture-Dislocation • Clinically • radial head palpable in anterolateral or posterolateral location • Forearm may appear shortened and angulated • Xray • Ulnar fx clearly visible, may overshadow less obvious radial head dislocation • Tx • ORIF of ulna • Closed reduction of radial head dislocation

19. Galeazzi and Monteggia

20. Biceps Rupture • Proximal (long head) • MOI: repetitive microtrauma (chronic bicipital tenosynovitis), sudden contraction vs resistance • Snap/pop, pain in anterior shoulder, mid arm “ball” • Xray: look for avulsion fx • Tx: sling, ice, analgesics, ortho referral

21. Triceps Rupture • Rare • Distal more common, young men • MOI: FOOSH causing forceful flexion of extended forearm, direct blow to olecranon • Clinically: sulcus with a more proximal mass, if complete- inability to extend forearm • Xray: look for avulsion of olecranon • Tx: sling, ice, analgesics, ortho referral • Compete tear: surgery • Partial tear: immobilization